Hospitals Know What’s Coming
“We are on an absolutely catastrophic path,” said a COVID-19 doctor at America’s best-prepared hospital.
Perhaps no hospital in the United States was better prepared for a pandemic than the University of Nebraska Medical Center in Omaha.
After the SARS outbreak of 2003, its staff began specifically preparing for emerging infections. The center has the nation’s only federal quarantine facility and its largest biocontainment unit, which cared for airlifted Ebola patients in 2014. The people on staff had detailed pandemic plans. They ran drills. Ron Klain, who was President Barack Obama’s “Ebola czar” and will be Joe Biden’s chief of staff in the White House, once told me that UNMC is “arguably the best in the country” at handling dangerous and unusual diseases. There’s a reason many of the Americans who were airlifted from the Diamond Princess cruise ship in February were sent to UNMC.
In the past two weeks, the hospital had to convert an entire building into a COVID-19 tower, from the top down. It now has 10 COVID-19 units, each taking up an entire hospital floor. Three of the units provide intensive care to the very sickest people, several of whom die every day. One unit solely provides “comfort care” to COVID-19 patients who are certain to die. “We’ve never had to do anything like this,” Angela Hewlett, the infectious-disease specialist who directs the hospital’s COVID-19 team, told me. “We are on an absolutely catastrophic path.”
To hear such talk from someone at UNMC, the best-prepared of America’s hospitals, should shake the entire nation. In mid-March, when just 18 Nebraskans had tested positive for COVID-19, Shelly Schwedhelm, the head of the hospital’s emergency-preparedness program, sounded gently confident. Or, at least, she told me: “I’m confident in having a plan.” She hoped the hospital wouldn’t hit capacity, “because people will have done the right thing by staying home,” she said. And people did: For a while, the U.S. flattened the curve.
But now about 2,400 Nebraskans are testing positive for COVID-19 every day—a rate five times higher than in the spring. More than 20 percent of tests are coming back positive, and up to 70 percent in some rural counties—signs that many infections aren’t being detected. The number of people who’ve been hospitalized with the disease has tripled in just six weeks. UNMC is fuller with COVID-19 patients—and patients, full stop—than it has ever been. “We’re watching a system breaking in front of us and we’re helpless to stop it,” says Kelly Cawcutt, an infectious-disease and critical-care physician.
Cawcutt knows what’s coming. Throughout the pandemic, hospitalizations have lagged behind cases by about 12 days. Over the past 12 days, the total number of confirmed cases in Nebraska has risen from 82,400 to 109,280. That rise represents a wave of patients that will slam into already beleaguered hospitals between now and Thanksgiving. “I don’t see how we avoid becoming overwhelmed,” says Dan Johnson, a critical-care doctor. People need to know that “the assumption we will always have a hospital bed for them is a false one.”
What makes this “nightmare” worse, he adds, “is that it was preventable.” The coronavirus is not unstoppable, as some have suggested and as New Zealand, Iceland, Australia, and Hong Kong have resoundingly disproved—twice. Instead, the Trump administration never mounted a serious effort to stop it. Whether through gross incompetence or deliberate strategy, the president and his advisers left the virus to run amok, allowed Americans to get sick, and punted the consequences to the health-care system. And they did so repeatedly, even after the ordeal of the spring, after the playbook for controlling the virus became clear, and despite months of warnings about a fall surge.
Not even the best-prepared hospital can compensate for an unchecked pandemic. UNMC’s preparations didn’t fail so much as the U.S. created a situation in which hospitals could not possibly succeed. “We can prepare over and over for a wave of patients,” says Cawcutt, “but we can’t prepare for a tsunami.”
A full hospital means that everyone waits. COVID-19 patients who are going downhill must wait to enter a packed intensive-care unit. Patients who cannot breathe must wait for the many minutes it takes for a nurse elsewhere in the hospital to remove cumbersome protective gear, run over, and don the gear again. On Tuesday, one rapidly deteriorating patient needed to be intubated, but the assembled doctors had to wait, because the anesthesiologists were all busy intubating four other patients in an ICU and a few more in an emergency room.
None of the people I spoke with would predict when UNMC will finally hit its capacity ceiling, partly because they’re doing everything to avoid that scenario, and partly because it’s so grim as to be almost unthinkable. But “we’re rapidly approaching that point,” Hewlett said.
When it arrives, people with COVID-19 will die not just because of the virus, but because the hospital will have nowhere to put them and no one to help them. Doctors will have to decide who to put on a ventilator or a dialysis machine. They’ll have to choose whether to abandon entire groups of patients who can’t get help elsewhere. While cities like New York and Boston have many big hospitals that can care for advanced strokes, failing hearts that need mechanical support, and transplanted organs, “in this region, we’re it,” Johnson says. “We provide care that can’t be provided at any other hospital for a 200-mile radius. We’re going to need to decide if we continue to offer that care, or if we admit every single COVID-19 patient who comes through our door.”
During the spring, most of UNMC’s COVID-19 patients were either elderly people from nursing homes or workers in meatpacking plants and factories. But with the third national surge, “all the trends have gone out the window,” Sarah Swistak, a staff nurse, told me. “From the 90-year-old with every comorbidity listed to the 30-year-old who is the picture of perfect health, they’re all requiring oxygen because they’re so short of breath.”
This lack of pattern is a pattern in itself, and suggests that there’s no single explanation for the current surge. Nebraska reopened too early, “when we didn’t have enough control, and in the absence of a mask mandate,” Cawcutt says. Pandemic fatigue set in. Weddings that were postponed from the spring took place in the fall. Customers packed into indoor spaces, like bars and restaurants, where the virus most easily finds new hosts. Colleges resumed in-person classes. UNMC is struggling not because of any one super-spreading event, but because of the cumulative toll of millions of bad decisions.
When the hospital first faced the pandemic in the spring, “I was buoyed by the realization that everyone in America was doing their part to slow down the spread,” Johnson says. “Now I know friends of mine are going about their normal lives, having parties and dinners, and playing sports indoors. It’s very difficult to do this work when we know so many people are not doing their part.” The drive home from the packed hospital takes him past rows of packed restaurants, sporting venues, and parking lots.
To a degree, Johnson sympathizes. “I don’t think people in Omaha thought we could ever have something that resembles New York,” he told me. “To be honest, in the spring, I would have thought it extremely unlikely.” But he adds that the Midwest has taken entirely the wrong lesson from the Northeast’s ordeal. Instead of learning that the pandemic is controllable, and that physical distancing works, people instead internalized “a mistaken belief that every curve that goes up must come down,” he said. “What they don’t realize is that if we don’t change anything about how we’re conducting ourselves, the curve can go up and up.”
Speaking on Tuesday afternoon, Nebraska Governor Pete Ricketts once again refused to issue a statewide mask mandate. He promised to tighten restrictions once a quarter of the state’s beds are filled with COVID-19 patients, but even then, some restaurants will still offer indoor dining; gyms and churches will remain open; and groups of 10 people will still be able to gather in enclosed spaces. Ricketts urged Nebraskans to avoid close contact, confined areas, and crowds, but his policies nullify his pleas. “People have the mistaken belief that if the government allows them to do something, it is safe to do,” Johnson said.
There are signs that citizens and businesses are acting ahead of policy makers. Some restaurants are ceasing indoor dining even without a prohibition. Parents are pulling their children out of schools and sports leagues. “I have heard from more friends and family about COVID-19 in the last two weeks than I have in the previous six months, expressing support and a change in attitudes,” Johnson said.
But COVID-19 works slowly. It takes several days for infected people to show symptoms, a dozen more for newly diagnosed cases to wend their way to hospitals, and even more for the sickest of patients to die. These lags mean that the pandemic’s near-term future is always set, baked in by the choices of the past. It means that Ricketts is already too late to stop whatever UNMC will face in the coming weeks (but not too late to spare the hospital further grief next month). It means that some of the people who get infected over Thanksgiving will struggle to enter packed hospitals by the middle of December, and be in the ground by Christmas.
Officially, Nebraska has 4,223 hospital beds, of which 1,165—27 percent—are still available. But that figure is deceptive. It includes beds for labor and deliveries, as well as pediatric beds that cannot be repurposed. It also says nothing about how stretched hospitals have already become in their efforts to create capacity. UNMC has postponed elective surgeries—those which could be deferred for four to 12 weeks. Patients with strokes and other urgent traumas aren’t getting the normal level of attention, because the pandemic is so all-consuming. Clinical research has stopped because research nurses are now COVID-19 nurses. The hospital is forced to turn down many requests to take in patients from rural hospitals and neighboring states that are themselves almost out of beds.
Empty hospital beds might as well be hotel beds without doctors and nurses to staff them. And though health-care workers are resilient, “many of us feel like we haven’t had a day off since this thing began,” Hewlett says. The current surge is pushing them to the limit because people with COVID-19 are far sicker than the average patient. In an ICU, they need twice as much attention for three times the usual stay. To care for them, UNMC’s nurses and respiratory therapists are now doing mandatory overtime. The hospital has tried to hire travel nurses, but with the entire country calling for help, the pool of reinforcements is dry. “Even before COVID-19 hit, we were short-staffed,” says Becky Long, a lead nurse on a COVID ICU floor. Of late, there have been days when the hospital had 45 to 60 fewer nurses than it needed. “Every time I’ve been at work, I’ve thought: This is going to be the final straw. But somehow we continue to make it work, and I truly have no idea how.”
Before COVID-19, Long worked in oncology. Death is no stranger to her, but she tells me she can barely comprehend the amount she has seen in recent weeks. “I used to be able to leave work at work, but with the pandemic, it follows me everywhere I go,” she said. “It’s all I see when I come home, when I look at my kids.”
Long and other nurses have told many families that they can’t see their dying loved ones, and then sat with those patients so they didn’t have to die alone. Lindsay Ivener, a staff nurse, told me that COVID-19 had recently killed an elderly woman whom she was caring for, the woman’s husband, and one of her grandchildren. A second grandchild had just been admitted to the hospital with COVID-19. “It just tore this whole family apart in a month,” Ivener said. “I couldn’t even cry. I didn’t have the energy.”
Until recently, Ivener worked in corporate America as a retail buyer and inventory manager. Wanting to help people, she retrained as a nurse and graduated this May. “I’ve only worked as a nurse during a pandemic,” she told me. “It’s got to get better, right?”